Back to Standards/Criterion 09D.4.3.25
Surveyor Consensus & Allocation Dispute
Team leader to resolve
Lead SurveyorDr Mohd Anis HaronAssigned Service Standard Lead
Rating SurveyorNot met
Mr Ganesh PillaiRecorded finding during tracer inspection

Awaiting Dr Mohd Anis Haron (Lead Surveyor) resolution. Dual surveyor observations are recorded with full provenance and decided strictly by clinical leadership authority.

09D.4.3.25
Special requirements

Growth Monitoring Protocol 4.3

The Paediatric Services department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for growth monitoring.

Compliance Criteria

  • 1Approved standard operating procedure for growth monitoring reviewed within the last 3 years
  • 2Designated qualified personnel assigned to monitor day-to-day growth monitoring compliance
  • 3Regular documentation audits and evidence of corrective action implementation
  • 4Staff training records and competency assessments maintained in the department

Hospital Self-Rating

Rated by Dr. Wong Wei Jun on 25 Jan 2026

Evidence frozen on 30 March 2026 (14 days before survey)

"The department has established comprehensive operational policies for growth monitoring. Regular self-assessments and internal quality checks demonstrate consistent compliance across all operational shifts."

AccrediSense Intelligence
unsupported

No evidence documents attached to substantiate this self-assessment claim.

Unverified criteria:
  • Approved standard operating procedure for growth monitoring reviewed within the last 3 years
  • Designated qualified personnel assigned to monitor day-to-day growth monitoring compliance
  • Regular documentation audits and evidence of corrective action implementation
  • Staff training records and competency assessments maintained in the department
Derived from AccrediSense Evidence Engine · 0 documents attached against 4 compliance criteriaGovernance disclosure (1.4.1.4)

Evidence Documents (0)

A criterion with no document reads as unevidenced to the survey team.

Attach relevant hospital policies, registers, audit reports, or training records.

WW
Person-in-ChargeConsultant Paediatrician
Head of DepartmentHead of Clinical Services & Consultant Physician
AR
Surveyor Authority PaneAssigned: Mr. Ganesh Pillai (Engineering & Facilities Surveyor)

Surveyor Rating

Committed 15 Apr 2026
Hospital: Fully met → Surveyor: Not metDivergent
Committed Basis for Divergence:

"The hospital self-rated Fully Met, but surveyor on-site audit found no evidence of approved policy implementation, active tracking, or staff competency verification for growth monitoring in Paediatric Services."

Surveyor assessment revealed complete absence of structured monitoring logs and verified staff competency assessments for growth monitoring in Paediatric Services.

Formulate and approve a formal operational framework for growth monitoring with designated staff competencies and active surveillance.

Develop mandatory SOP, assign operational indicator oversight, and conduct staff training within 60 days.